Justia Public Benefits Opinion Summaries

Plaintiff applied for disability insurance benefits on January 30, 2020, alleging disability since March 1, 2017,due to PTSD, depression, anxiety, insomnia, headaches, and a right knee injury. His application was denied initially and upon reconsideration. A medical expert confirmed that Plaintiff would be markedly limited when interacting with others. The medical expert suggested that Plaintiff’s Residual Function Capacity (RFC) includes “some limitations in terms of his work situation.” Once the Appeals Council denied review of the ALJ’s decision, Plaintiff sought judicial review. The district court affirmed the agency’s denial of benefits. On appeal, Plaintiff only challenged the ALJ’s finding that his mental impairments were not disabling.   The Ninth Circuit affirmed. The panel held that the ALJ did not err in excluding Plaintiff's VA disability rating from her analysis. McCartey v. Massanari, 298 F.3d 1072, 1076 (9th Cir. 2002) (holding that an ALJ is required to address the Veterans Administration disability rating) is no longer good law for claims filed after March 27, 2017. The 2017 regulations removed any requirement for an ALJ to discuss another agency’s rating. The panel held that the ALJ gave specific, clear, and convincing reasons for rejecting Plaintiff's testimony about the severity of his symptoms by enumerating the objective evidence that undermined Plaintiff’s testimony. The panel rejected Plaintiff's contention that the ALJ erred by rejecting the opinions of Plaintiff’s experts. The panel held that substantial evidence supported the ALJ’s conclusion that Plaintiff’s mental impairments did not meet all of the specified medical criteria or equal the severity of a listed impairment. View "JEREMY KITCHEN V. KILOLO KIJAKAZI" on Justia Law

Plaintiff, MSP Recovery Claims, Series LLC (“MSP”) appealed from the district court’s judgment dismissing for lack of standing its putative class action against Defendant Hereford Insurance Company (“Hereford”) and denying leave to amend. MSP has brought several lawsuits around the country seeking to recover from insurance companies that allegedly owe payments to Medicare Advantage Organizations (“MAOs”) under the Medicare Secondary Payer Act (the “MSP Act”). In the putative class action brought here, MSP charges Hereford with “deliberate and systematic avoidance” of Hereford’s reimbursement obligations under the MSP Act.   The Second Circuit affirmed. The court concluded that MSP lacked standing because its allegations do not support an inference that it has suffered a cognizable injury or that the injury it claims is traceable to Hereford. The court also concluded that the district court did not abuse its discretion when it denied MSP leave to amend based on MSP’s repeated failures to cure. The court explained that the plain language of Section 111 provides that when a no-fault insurance provider such as Hereford reports a claim pursuant to Section 111, it does not thereby admit that it is liable for the claim. The statutory context of the section’s reporting obligation and the purpose of the reporting obligation confirms the correctness of this interpretation. Because MSP’s argument that the payments made by EmblemHealth are reimbursable by Hereford rests entirely on its proposed interpretation of Section 111, MSP has not adequately alleged a “concrete” or “actual” injury or that the injury it alleges is fairly traceable to Hereford. View "MSP v. Hereford" on Justia Law

Plaintiff appealed the district court’s order upholding a decision by the Commissioner of the Social Security Administration denying her disability insurance benefits and supplemental security income. She argued that the Commissioner’s decision was not supported by substantial evidence. Plaintiff contends that the ALJ failed to sufficiently articulate his rationale for rejecting Plaintiff’s treating physician’s opinion, rendering the ALJ’s decision legally erroneous and unsupported by substantial evidence on the record as a whole.   The Eighth Circuit affirmed. The court held that ALJ was justified in finding the physician’s opinion unpersuasive. The opinion’s bare, formulaic conclusion presumptively warranted little evidentiary weight “because it was rendered on a check-box and fill-in-the-blank form.” The physician checked some boxes and left blank the short-answer section asking what objective medical findings supported his assessment. The ALJ also found the checkbox form “unsupported and highly inconsistent” with the record because the physician’s conservative treatment plan, other medical opinions, and Plaintiff’s own descriptions of her activities contradict the checkbox assessment. View "Vickie Nolen v. Kilolo Kijakazi" on Justia Law

Plaintiff appealed the district court’s order affirming the Social Security Administration’s (“SSA”) denial of her application for Social Security Disability Insurance (“SSDI”). In her application, she alleged major depressive disorder (“MDD”), anxiety disorder, and attention deficit disorder (“ADHD”). Following a formal hearing, the Administrative Law Judge (“ALJ”) determined that Plaintiff suffered from severe depression with suicidal ideations, anxiety features and ADHD, but he nonetheless denied her claim based on his finding that she could perform other simple, routine jobs and was, therefore, not disabled. Plaintiff contends that the ALJ erred by (1) according to only little weight to the opinion of her long-time treating psychiatrist (“Dr. B”) and (2) disregarding her subjective complaints based on their alleged inconsistency with the objective medical evidence in the record.   The Fourth Circuit reversed and remanded with instructions to grant disability benefits. The court agreed with Plaintiff that the ALJ failed to sufficiently consider the requisite factors and record evidence by extending little weight to Dr. B’s opinion. The ALJ also erred by improperly disregarding Plaintiff’s subjective statements. Finally, the court found that the ALJ’s analysis did not account for the unique nature of the relevant mental health impairments, specifically chronic depression. The court explained that because substantial evidence in the record clearly establishes Plaintiff’s disability, remanding for a rehearing would only “delay justice.” View "Shelley C. v. Commissioner of Social Security Administration" on Justia Law

The Supreme Judicial Court reversed the order of the superior court allowing Plaintiff's motion for summary judgment in this lawsuit brought against the Executive Office of Health and Human Services and Nationwide Life Insurance Company in this dispute over the remainder of an annuity issued by Nationwide, holding that the superior court erred.Robert Hamel purchased the annuity at issue to help Joan Hamel, his wife, become eligible for Medicaid benefits, which was necessary to pay for her long-term care. Robert named the Commonwealth as the primary remainder beneficiary to the "extent benefits paid" and Plaintiff, his daughter, as the contingent remainder beneficiary. Before the end of the annuity period Robert died. Plaintiff filed this lawsuit alleging that she was entitled to the remainder. The superior court entered summary judgment in favor of Plaintiff and denied the Commonwealth's motion for summary judgment as to Plaintiff's claim for declaratory judgment. The Supreme Judicial Court vacated and reversed the judgment below, holding that, upon Robert's passing, the remainder of the annuity properly belonged to the Commonwealth up to the amount it paid for Joan's care. View "Dermody v. Executive Office of Health & Human Services" on Justia Law

Van Dermark served in the Navy from 1963 until his 1976 honorable discharge. The VA found Van Dermark to be totally and permanently disabled due to service-connected injuries. Van Dermark received treatment in Thailand (where he lived) at non-VA facilities, from physicians and others not affiliated with VA, in 2016 and in 2018, both times for cardiac conditions not related to his service-connected disability. For each of the two instances of treatment abroad, Van Dermark filed a claim with VA under 38 U.S.C 1728 and 1725 seeking VA payment—to him or his medical creditors—for the surgical or other heart-related treatment he received abroad.VA Community Care denied both claims. The Board of Veterans’ Appeals maintained the denials. The Veterans Court and Federal Circuit affirmed. Section 1724(a) prohibits the VA from “furnish[ing] hospital . . . care or medical services” abroad, where the care or services are unrelated to the service-connected disability. The “furnishing” phrase encompasses the payment for a veteran’s hospital care or medical expenses abroad at issue here; sections 1728 and 1725 do not override that prohibition. View "Van Dermark v. McDonough" on Justia Law

MSPA Claims 1 LLC—the assignee of a now-defunct Medicare Advantage Organization—sued Tower Hill Prime Insurance Company to recover a reimbursable payment. The district court granted Tower Hill’s motion for summary judgment because it determined that MSPA Claims 1’s suit was untimely.The Eleventh Circuit affirmed. The court explained that because it is at least “plausible” that the term “accrues” in Section 1658(a) incorporates an occurrence rule—in fact, and setting presumptions aside, the court wrote that it thinks that’s the best interpretation—that is how the court interprets it. Therefore, MSPA Claims 1’s cause of action accrued in 2012 when MSPA Claims 1’s assignor, Florida Healthcare, paid D.L.’s medical bills and became entitled to reimbursement through the Medicare Secondary Payer Act. Because that was more than four years before MSPA Claims 1 filed suit in 2018, its suit is not timely under 28 U.S.C. Section 1658(a). View "MSPA Claims 1, LLC. v. Tower Hill Prime Insurance Co." on Justia Law

Wolfe, who was enrolled in VA health care, obtained emergency treatment at a non-VA health care facility, incurring expenses of $22,348.25. Her employer-sponsored healthcare contract covered most of the expenses. She was responsible for a copayment of $202.93 and coinsurance of $2,354.41. The VA denied reimbursement of those expenses; 38 U.S.C. 1725(c)(4(D) bars reimbursement for “any copayment or similar payment.” Wolfe filed a Notice of Disagreement; rather than await the outcome of her appeal, Wolfe also filed a mandamus petition. The Veterans Court certified her requested class and granted her petition, invalidating a VA regulation prohibiting the reimbursement of deductibles and coinsurance for being within the category of “similar payments,” and requiring the VA to re-adjudicate claims denied under the invalidated regulation.The Federal Circuit reversed. Deductibles are excluded from reimbursement under the correct interpretation of the statute and other adequate remedies (appeal) were available with respect to coinsurance, so mandamus was inappropriate. Coinsurance is the type of partial coverage that Congress did not wish to exclude from reimbursement. View "Wolfe v. McDonough" on Justia Law

The issue this case presented for the New Jersey Supreme Court's review in this appeal was who bore the primary responsibility for the payment of Dale Mecouch’s medical bills arising from an automobile accident that took place before December 5, 1980: the issuer of an automobile insurance policy or Medicare. In 2016, Mecouch was hospitalized for approximately two months at Cooper Hospital University Medical Center (Cooper) due to complications arising from a 1977 automobile accident that left him paralyzed from the waist down. At the time of his accident, Mecouch had a no-fault automobile insurance policy with Selective Insurance Company of America (Selective), which provided Mecouch with unlimited personal-injury-protection (PIP) benefits. Sometime after 1979 but before 2016, Mecouch was enrolled in Medicare. Selective continued to pay Mecouch’s medical expenses related to the 1977 accident until December 11, 2015, when it notified Mecouch by letter that, going forward, “Medicare is the appropriate primary payer for any treatment related to” the 1977 accident. After Mecouch’s 2016 hospital stay, Cooper forwarded to Selective a bill for over $850,000 for medical services rendered to Mecouch. Instead of paying that bill, Selective directed Cooper to seek reimbursement from Medicare. Cooper was a participating Medicare provider, and, at that time, Mecouch was a Medicare enrollee. Cooper then billed Medicare, which issued a payment of under $85,000. Selective eventually agreed to reimburse Cooper for Mecouch’s co-payments and deductibles. Cooper filed a complaint against Selective, seeking the total cost of Mecouch’s care. The trial court granted summary judgment in favor of Cooper, awarding Cooper the cost of Mecouch’s care minus the amount covered by Medicare. The Appellate Division reversed, concluding Medicare was the “primary payer” for Mecouch's medical bills at Cooper. The Supreme Court concluded that because Mecouch was a Medicare enrollee in 2016, Cooper was required to bill and accept payment from Medicare, which promptly covered Mecouch’s medical expenses in accordance with its fee schedule. Cooper could not seek payment from Selective other than for reimbursement of the Medicare co-payments and deductibles. View "Cooper Hospital University Medical Center v. Selective Insurance Company of America" on Justia Law

Peggy Harvey and Eileen Manzanares were injured in separate car accidents when their cars were struck by other drivers. Each was then taken to a Centura-affiliated hospital (along with Centura Health Corporation, “Centura”) for treatment. At the time they were treated by Centura, both women’s health insurance was solely through Medicare and Medicaid. And both women’s injuries resulted in hospital stays. In addition to Medicare and Medicaid, both women had automobile insurance whose policies included medical payment ("Med Pay") coverage for medical bills incurred as a result of a motor vehicle accident. In addition, the third-party tortfeasors who caused Harvey’s and Manzanares’s injuries also had automobile insurance. Both Harvey and Manzanares advised Centura of all of the available health and automobile insurance policies. Centura then assigned the women’s accounts to a collection agency, Avectus Healthcare Solutions, for processing; Avectus submitted Centura’s medical expenses to each of the automobile insurers involved, including the automobile insurers for Harvey, Manzanares, and the third-party tortfeasors. Within two weeks after submitting these charges to the various automobile insurers (and within two months of the women’s respective discharges from their hospital stays), Centura filed hospital liens against both of the women. Centura conceded it did not bill either Medicare or Medicaid before filing their respective liens. Both Harvey and Manzanares subsequently brought suit, alleging that Centura had violated the Lien Statute by not billing Medicare for the services provided to the women prior to filing the liens. The parties disputed whether when, as here, Medicare was a person’s principal source of health coverage, Medicare could be considered a “primary medical payer of benefits” under the Lien Statute (such that a hospital must bill Medicare before asserting a lien), or if such an interpretation was barred by the Medicare Secondary Payer statute, which designated Medicare as a “secondary payer.” The Colorado Supreme Court concluded that when Medicare was a patient’s primary health insurer, the Lien Statute required a hospital to bill Medicare for the medical services provided to the patient before asserting a lien against that patient. "Hospital liens are governed by state, not federal, law, and merely enforcing our Lien Statute does not make Medicare a primary payer of medical benefits in violation of the MSP Statute." View "Harvey v. Centura, No." on Justia Law